10 May Hospitals Overhaul ERs to Reduce Mistakes

The Wall Street Journal | An 18-year-old man with fever and chills is sent home from the emergency room with Tylenol and later dies of sepsis, a blood infection. A 42-year-old woman with chest pains is discharged, only to suffer a heart attack two hours later. A 9-year-old girl’s appendix ruptures after doctors rule she’s just got a bellyache.

Hospitals are drawing on lessons learned from these worst cases of missed or delayed diagnosis to overhaul emergency departments, where errors, oversights and a lack of teamwork between doctors and nurses can harm or kill patients. They are adopting new triage systems to ensure doctors and nurses jointly see at-risk patients soon after they arrive, requiring physicians and nurses to huddle to make sure no information is overlooked, and using time-outs at discharge to prevent patients with unresolved problems from leaving the ER.

Often chaotic and overcrowded, with scant data available about new patients, the emergency room is among the top hospital departments responsible for malpractice suits—and diagnostic errors account for 37% to 55% of cases in studies of closed claims. The average payments and legal expenses for ER cases have more than doubled over the past two decades, according to the Physician Insurers Association of America, a nonprofit trade association whose members cover about 60% of emergency physicians.

While emergency-room errors often happen because a doctor misjudges symptoms, in almost all cases of missed or delayed diagnoses essential pieces of information weren’t available at the time the doctor made a decision, according to Dana Siegal, program director of risk-management services for Crico/RMF Strategies, whose parent company insures hospitals affiliated with Harvard University.

Gaps can include a missing medical history, no record of abnormal vital signs such as blood pressure or heart rate, a lack of timely access to radiology or lab reports, or information lost in a shift change. Crico’s analyses show poor doctor-nurse communication at critical times often causes mistakes.

Crico/RMF is working with 16 hospitals on a project to improve communication between doctors and nurses. Mannequins will be used to simulate various emergencies, and participants discuss what could have been done differently.

Among the strategies being tried by participating hospitals is a new system for triaging patients, dividing the emergency department into separate areas, such as pediatrics, obstetrics and psychiatry.